In January, the FDA approved the medication Hetlioz, a melatonin receptor agonist, to treat non-24-hour sleep-wake disorder. This medication is now available through Harvard Pilgrim’s specialty pharmacy program with prior authorization. It will be covered at Tier 3 for 3-Tier formulary and Tier 4 for 4-Tier formulary.
Prior authorization is required to ensure that Hetlioz is used only for its FDA-approved indication (non-24-hour sleep-wake disorder) and in the appropriate dosage (1 20-mg capsule per day at bedtime). Approvals will be for 1 20-mg capsule per day for a 12-month period.
To obtain prior authorization, please refer to the Hetlioz Clinical Criteria, and complete the appropriate Medication Request Form and fax it back to MedImpact Healthcare Systems at 888-807-6643.
Hetlioz will be offered through the specialty pharmacy Accredo. For more information, please visit Harvard Pilgrim’s pharmacy page.